#RCN18 – Therapeutic Staffing

A few people asked for the text of the RCN Mental Health Forum resolution on Therapeutic Staffing, so here it is:

Thank you for considering this resolution – that this meeting of RCN Congress calls on Council to commission research into therapeutic staffing levels for mental health nursing.

There’s so much going on around safe staffing numbers – across regions now and by this College over the last year, and onward campaigning for legally mandated numbers as Janet announced in her keynote address. Today we seek to build on that, contending that staffing guidance for mental health settings must, at the very core, include the therapeutic effect of the mental health nurse. To do so requires research; that’s what I’m asking you to vote for.

I cannot, in a few short minutes, explain in detail the particular parameters of this project; that work will be done in coming months. Right now I hope to sketch out the concept of our therapeutic role, and say why this work is necessary.

Congress, I am a tool – a therapeutic tool; my skills make Ed the Mental Health Nurse a clinical instrument, a psychiatric obs machine, an emotional central line perhaps. Our skills are psychosocial and interpersonal, observation and dialogue. My interactions with a patient have a positive effect on their mental health. To illustrate:

I know in my practice that a chat over a coffee is as important as doing baseline obs. I know in my practice that spending time listening to a person’s fears and dreams can be as vital as a surgical procedure. I know from my practice that being too busy to listen is a clinical incident that can lead to harm. Sometimes in passing you ask someone how they’re doing, and they actually tell you – that requires an investment of time. That requires having more staff than just covering the paperwork and dishing out the drugs. That requires doing activities that at present are not given priority.

Inadequately staffed teams have to cancel activities – a daily occurrence for many. Activities like planned leave (maybe for the first time in months), 1:1 or group sessions, home visits, care planning or even just having that coffee – all as essential as dressing a wound – and all are the first casualties of short staffing.

Work on minimum staffing continues, but we must consider factors like interpersonal relationships, continuity of care, protected time, supervision and wellbeing, as well as dynamic and human factors. Working to a minimum may underestimate the level of staffing required to maintain a therapeutic benefit.

A focus on keeping things safe makes our practice risk-averse, to the detriment of recovery; hitting the symptoms not the illness, it becomes about containment, not treatment. A quiet, compliant ward is not our goal. Mental health nurses must not be reduced to mere custodians.

Staff planning, in practice, has wide regional variances – mostly without an evidence base – indeed half of England’s Mental Health Trusts go beyond planned staffing levels because need and acuity is consistently higher than anticipated.

The current approach is not working. The models, where they exist, don’t serve the reality. A reactive, ad hoc muddle-through helps no-one, it’s expensive and impedes recovery. And the current approach leads to disillusionment, as we have already discussed this week. The gulf between what we want to do and what we can do is heartbreaking. Little wonder we struggle to recruit and retain.

Creating and sustaining therapeutic relationships is an important issue for research because nurses have the most contact with service users. Those in our care value that relationship – fostering trust, communication and recovery. Nurses are the most trusted profession for good reason.

Our role has always been hard to define, and therefore always hard to capture. Today we are asking for research to demonstrate the efficacy of our clinical role; that then allows us to take bold, positive action to improve how mental health nursing is delivered nationally.

Staffing guidance in mental health settings must focus on providing an effective, therapeutic environment. We need the people, supervision, support and time to make sure every service user can establish and benefit from successful therapeutic relationships.

We need to describe a clear role, protecting the skills that make therapeutic interaction possible. And we need to identify leaders who can realise these goals.

This week we have heard more about the problems of recruitment and retention in nursing. Perhaps it is naive to be chasing an understanding of therapeutic practice in the face of such pressures, but without a target we have nothing to aim for. These are not laudable ambitions for a distant utopia but desperately needed objectives for today.

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